The largest maternity review in NHS history is set to be published on Wednesday, detailing care failings that led to the deaths of babies and mothers at Nottingham University Hospitals (NUH) NHS Trust. Around 2,500 families and more than 800 staff members have provided evidence to the probe, which covers suspected failings from 2012 to 2025.
Families' Pleas Ignored
Parents have described how their pleas for help during pregnancy were repeatedly ignored until it was too late. Senior physiotherapist Sarah Hawkins and her husband Jack, a hospital consultant, both worked at NUH when they were expecting their first child, Harriet, in April 2016. Despite making 10 calls to the maternity unit and visiting twice over six days of labour, they were told to stay home and relax, even after raising concerns that Sarah couldn't feel the baby moving.
When Sarah was finally admitted, midwives struggled to find Harriet's heartbeat, and a scan revealed she had died. Jack said: “I’m heartbroken that my first daughter Harriet is not here. She should be alive and yet, 10 years later, so many of our questions have not been answered and not one single person has been held accountable.” An external inquiry later found 13 failings in care and deemed Harriet's death “almost certainly preventable.”
Emmie's Story: 'The Last Thing I Saw Was Blood'
Emmie Studencki, 37, from Barrowby, Lincolnshire, experienced bleeding late in her second pregnancy in 2021. She visited hospital three times but was sent home each time. During a fourth bleed, she lost over two pints of blood and was taken to Nottingham by ambulance, but her ambulance notes were lost. Requests for a caesarean section were denied, with staff saying: “You’ve given birth before, you can do it again.”
Unbeknownst to the couple, Emmie was suspected of having a placental abruption. A heart rate monitor showed baby Quinn's heart fluctuating in distress. Emmie developed severe pain and screamed, but a nurse refused an emergency C-section, encouraging her to walk instead. When a doctor eventually broke her waters, it triggered a massive haemorrhage, and Emmie lost seven pints of blood. She recalled: “The last thing I saw was blood everywhere and the next thing I knew I was coming around from surgery.”
After waking, staff initially told her Quinn was fine, then that he was “very poorly.” They kept the couple apart for over 10 hours before acknowledging Quinn would not survive. Emmie said: “They robbed our time with him from us. We will never forgive them for that.” Quinn died in their arms at two days old. An inquest in 2022 found a “series of errors.” NUH was fined £1.6 million last year after admitting criminal charges for causing avoidable harm to Quinn and exposing his mother to significant risk.
Wider Failings and Legal Actions
Gary and Sarah Andrews lost their daughter Wynter in 2019, 23 minutes after birth. NUH was fined £800,000 for failings in their care. Gary said: “The report being published today needs to serve as a wake-up call to the NHS locally and nationally, that what's gone on before cannot be allowed to continue.”
Nottinghamshire Police launched a corporate manslaughter case last year as part of a wider criminal investigation. On Monday, two men aged 55 and 59 were arrested on suspicion of misconduct in a public office in connection with “operating practices in the mortuary service.” The General Medical Council and Nursing and Midwifery Council are also investigating individual staff.
The Ockenden report, led by top midwife Donna Ockenden, will be published around midday on Wednesday. The trust has already paid millions in compensation for failings leading to deaths and life-changing injuries.
